[Hiring] Investigator @Integrity Management Services, Inc.

Role Description

In this role, the Investigator will perform high level complex Medicare and Medicaid investigations and develop cases for future action, including referral to law enforcement, education, overpayment recovery and other administrative actions. The Investigator will work with internal resources and external agencies to develop cases and administrative actions as well as respond to requests for data and support. The Investigator works independently as well as collaboratively with various team members and managers.

• Conduct thorough investigations into alleged healthcare fraud, waste, and abuse (FWA) by researching relevant offenses, reviewing records, performing interviews, and collecting evidence through observation and document examination.
• Analyze investigative findings to determine whether allegations are substantiated; collaborate with colleagues, including data analysts and subject matter experts, to develop appropriate corrective actions or referrals.
• Develop, document, and maintain comprehensive case files in accordance with investigative standards, including timely updates in databases and case tracking tools.
• Conduct research on Medicare and Medicaid claims data and other sources of information to establish policy requirements.
• Prepare detailed investigative reports that apply federal or state laws, rules, or regulations to the affected programs, clearly documenting findings to support follow-up actions or enforcement referrals.
• Coordinate with internal teams and external agencies—including law enforcement, legal counsel, CMS, and state or federal investigators—on joint investigations, case development, and information-sharing efforts.
• Conduct background research on suspect providers to identify adverse business relationships, sanctions, exclusions, or other disqualifying information.
• Review and interpret relevant healthcare policies, regulations, and instructions to support findings and recommendations in FWA cases.
• Maintain high standards in fraud case development, ensuring that evidence is properly collected, documented, and safeguarded in compliance with rules of evidence and investigative guidelines.
• Perform data analysis on claims data to identify patterns or anomalies indicative of FWA; contribute insights to the development of new fraud scheme detection methodologies.
• Respond to law enforcement and client requests for data, documentation, or investigative support within specified timeframes.
• Review and approve all administrative action requests prior to submitting to CMS and provide training and mentoring.
• Maintain statistics on all submitted administrative actions and maintain template documents used to submit and process administrative actions.
• Conduct on-site visits and in-person interviews when required as part of investigative activities.

Qualifications

• Bachelor degree in business or related field with 5-7 years experience (e.g., law enforcement investigation, statistics, data analysis).
• 6+ years investigative experience in the Healthcare industry.
• At least 3 years of experience in benefit integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
• Knowledge of CMS Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions.
• Strong investigative skills.
• Advanced data analysis skills.
• Knowledge of medical terminology, ICD-9-CM, ICD-10-CM HCPCS level II and CPT codes. Utilizes Medicaid and Contractor guidelines for coverage determinations.
• Experience in reviewing claims for appropriate billing and medical coding requirements, performing medical review, and/or developing fraud cases.
• Certified Fraud Examiner (CFE) or Accredited Health Care Fraud Investigator (AHFI). (Preferred)
• Must pass post hire background screening checks.
• For remote work, required to have wired and/or wireless internet access.
• Ability to obtain security clearance, if required by Client/Contract.

Benefits

• Vacation
• Sick leave
• Paid holidays
• Health insurance
• Dental insurance
• Vision insurance
• Short- and long-term disability
• Life insurance
• Employee assistance plan
• 401(K) retirement plan
• Educational benefits

Salary Information

U.S. remote annual salary range: $50,000-$70,000/annual. For candidates in jurisdictions requiring range disclosure, this is the good-faith range for this role; final pay may vary by work location and job-related factors such as skills, experience, location, and internal equity. This is not, however, a guarantee of compensation or salary. Rather, salary will be set based on experience, geographic location and possibly contractual requirements and could fall outside of this range.

Equal Opportunity Employer

IntegrityM is an Equal Opportunity Employer and we do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, and gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.